brånemark system - dr. carlos aparicio: all about … biomechanical considerations number of...

procedures & products

Brånemark System ®

Zygoma

Nobel Biocare is in compliance w ithISO 13485:1996 and Council D irective 93/42/EEC

Canadian Medical Devices Regulation

0086

For USA only: Federa l law restricts this device to sa le by or on the order of a licensed dentist or physician.All products are subject to change w ithout notice.

Some products may not be available in all markets. Please contact your local Nobel Biocare officefor current product assortment and availability

First from Nobel Biocare. N OBELPERFECT®, (NP, RP, WP), N OBELDIRECT® (NP, RP, WP), Brånemark System®, N OBELREPLACE™ and

N OBELSPEEDY™ Implants. A complete assortment with FDA clearance for Immediate Function™

in a ll single, partia l and fully edentulous restorations in the mandible and maxilla .

Nobel Biocare AB and all production units are certified according to the Environmental Management System ISO 14001

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Brånem ark System ® Zygom a

Table of contentBeautiful Teeth Now™

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Pre-surgical Treatment PlanningOsseoconductive implant surfaces. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5Pre-surgical Prosthetic Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6Biomechanical Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

General Pre-surgical Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Recommended Electronic Equipment & Machinery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Pre-operative Radiographic Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

SurgeryStandard Le Fort 1 Incision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13Operating Instruments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Implant Installation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18Installation Sequence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Suturing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Implant Removal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Packaging – Plastic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Packaging – Glass . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Depth Measurement System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Abutment ConnectionUncovering and Abutment Connection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27Prosthetic Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

Rigid Bar Splinting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

Product Catalog . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

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For abstracts, study references and for more information,please visit our website: www.nobelbiocare.com

Beautiful teeth now™

Congratulations! You have made an excellent choice. Wel-come to the Nobel Biocare fam ily. Nobel Biocare is provid-ing dentists w ith more choices than ever before. But ourgoals remain the same:

• To ensure that your patients leave the treatment roomsatisfied, comfortable, with beautiful teeth and with arenewed quality of life.

• To help your practice run more smoothly, efficiently and profitably.

This manual is designed to provide quick access to importantinformation regarding treatments, procedures and optionsfor the solution based on the Brånemark System® ZygomaTiUnite™ implant system.

Nobel Biocare solutions are designed to facilitate:

• Short & long-term Easy esthetics• Patient comfort


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Pre-Surgical treatment planning

Osseoconductive implant surfaces

The TiUnite surface on Nobel Biocare Implants has beenshown to support the healing process and better mainte-nance of the initial implant stability than machined titaniumimplants. TiUnite is a highly Osseoconductive surface.

Indications

1. Where sufficient anterior bone remains for the installationof standard Brånemark System® implants and the posterioralveolar crest has resorbed to such an extent, that addition-al implants would otherwise require the support of onlay orinlay grafts.

2. Where an anterior onlay graft is required for implant place-ment and the need to extend the graft posteriorly can beeliminated by placing the Zygoma implant.

3. The partially edentulous maxilla with uni- or bilateral lossof premolars and molars, combined w ith severe boneresorption. In such situations, a Zygoma implant, in combi-nation w ith at least two regular implants, w ill offer ade-quate support for a fixed restoration.


The unique combination of controlledtitanium oxide texture and porositymakes bone grow directly onto and intothe surface. (Courtesy of Dr PeterSchüpbach, Sw itzerland)

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Pre-surgical Prosthetic Considerations

There are many factors which contribute to the long-termsuccess of this technique. It is important to carefully evaluateas many of these factors as possible before the surgical proce-dure is started. In order to achieve proper treatment planning and secure long-termsuccess, an effective team approach must be established.

The pre-surgical prosthetic examination and evaluationshould include:

• the facial profile and contours

• any parafunctional habits

• the horizontal and vertical jaw relationships

• the occlusal plane orientation

• the occlusal relationships

• the status of the opposing dentition

Position and angulation of implants

The tooth positions for the planned restoration should bedecided preoperatively. This will allow the most appropriateposition and angulation to be selected for each implant. Theexisting removable prosthesis will often serve as a guide forthese positions. In some instances a diagnostic wax-up will benecessary. It is up to the prosthetic team to ensure that thesurgical team has a clear understanding of the tooth positionsrequired for the final prosthesis. One of the most appropriatemeans of doing this is by providing a surgical guide. A simpleand quick way of fabricating a surgical guide is to make areplica, in clear acrylic resin, either of the existing removabledenture or of the waxed-up try-in. The palatal area of thereplica, except for a supporting posterior connection, is thencut away leaving only the buccal contours of the teeth.


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Biomechanical Considerations

Number of implants

When compared to a standard implant, the Zygoma implanthas an increased tendency to bend under horizontal loads.This is related to two factors:

1. The greatly increased length of these implants (30-52.5 mm)

1. The fact that in some circumstances there is limited bonesupport in the maxillary alveolar crest.

Consequently, these implants should be rigidly connected tostable conventional fixtures in the anterior maxilla. Based onclinical experience and biomechanical theoretical calculations(ref. Zhao, Skalak), a full arch restoration in the maxilla, sup-ported by two Zygoma implants (one on each side), shouldbe assisted by at least two stable regular Brånemark Systemimplants in the anterior maxilla.

Bending moments

Forces that cause bending moments are known to be themost unfavorable. These forces can potentially jeopardize thelong-term stability of an implant-supported restoration. Inorder to decrease bending moments, the distribution offorces should be optimized by:

• cross arch stabilization

• decreased buccal lever arms

• decreased cantilevers

– mesial/distal and anterior/posterior

• balanced occlusion

• decreased cuspal inclination


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Prosthetic design

General guidelines for prosthetic design when utilizing theZygoma implant should include efforts to:

• incorporate sufficient rigidity and precision in the restoration

• decrease bending moments

• balance functional, esthetic, phonetic, and hygiene require-ments

• facilitate maintenance

If the prosthesis is insufficiently rigid, deformation and deflectionof the zygoma implant can lead to implant loss or screw loosen-ing.

Local anatomy

The Zygoma implants typically pierce the oral mucosa in thepremolar region, and are in a slightly more palatal position com-pared to the implants in a standard maxillary restoration. It isimportant for the surgeon to carefully confirm the position ofthe implant head at the time of implant insertion. The directionand position of the screw attaching the implant mount to theimplant represents the future position of the abutment screw.

Stability = in the bridge frameworkPrecision = in the connecting screw joints


Precision

Stability

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General pre-surgical examinationThe same pre-surgical routine is used as for any other intra-oral surgi-cal procedure requiring local or general anesthesia.

Prior to surgery, the patient

• must have clinically symptom-free sinuses

• must have no pathology in associated bone and soft tissue

• must have completed any necessary dental treatment

Recommended Electronic Equipment & MachineryFor OsseoSet 100 users Article No

Handpiece Zygoma 20:1 32615

Note: Do not use with parts from any other sources. Any manipulation isimpermissible and may result in damage or injury. Handpiece Zygoma is amedical product according to the applicable national provisions of law.

Recommendations for using surgical units other than OsseoSet™ 100

The possibility to adjust the gear mechanism of the

contra-angle handpiece to 20:1 ratio.

Maximum drill speed limited to 2000 rpm.

Maximum speed for implant installation limited to 45 rpm.

Maximum torque for implant installation limited to 50 Ncm.


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Pre-operative radiographicexam inationThe radiographic examination of the resorbed frontal alveo-lar bone of the upper jaw is performed, applying the sameprinciples as for standard implant installation:

Panoramic image to identify anatomic structures and detectpathological changes within the jaw.

Intraoral radiographs in the frontal area as a supplement topanoramic image to exclude pathology.

Lateral cephalogram (profile radiograph) to evaluate jaw widthin the midline to determine the sagittal relationship betweenjaws.

Tomography, conventional or computed tomography todetermine available bone volume in the frontal area as well asin the posterior area.

The objectives of radiographic examination of the zygomaticbone are:

• to detect pathology in the maxillary sinus.

• to evaluate zygomatic bone volume. Note that the exten-sion of the maxillary sinus into the zygomatic bone showslarge individual variations. Even within the same individual,there may be a difference between right and left.

• to determine the topography of the anterior wall of the tem-poral fossa, the presence of concavities.

• to estimate the thickness of the alveolar process to the max-illary sinus in the premolar region for bone support of theZygoma implant.


Techniques

For this kind of treatment, two optional radiographic tech-niques are highly recommended. The first is computedtomography and the second is conventional tomography.

Computed tomography with axial or coronal (frontal) scans.

• Axial scans (scan plane parallel to hard palate) are prefer-able, as the scan plane is identical to the one used for frontalalveolar bone.

• Reformatted frontal images, produced in a plane perpendi-cular to the scan plane, show the extension of the maxillarysinus into the zygoma and the thickness (width) andheight of the zygomatic body can thus be determined.

• Both axial scans and reformatted images show whetherpathology of the maxillary sinus exists.

• 3D reconstructions of the zygomatic bone can be useful forthe topographic evaluation of the temporal fossa (anteriorwall).

It is essential that the CT scan images concern the maxilla, thetotal sinus height as well as the total zygoma height.

Conventional tomography

• Multidirectional motions (spiral, hypocycloidal) are pre-ferred.

• Frontal tomograms (2–4 images some mm apart) perpendi-cular to the hard palate.

• These frontal tomograms demonstrate the extension of themaxillary sinus. Sinus disease can be diagnosed. The imagesdo not visualize the anterior wall of the temporal fossa.

• The thickness of the alveolar bone between the maxillarysinus and palatal outer border of the crest can be deter-mined.

• If the Scanora® technique is available, sinus tomographicprograms, or preferably maxillodental tomographic pro-grams with thinner layer thickness, can be used.

Frontal conventional tomogram

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Precautions

• Avoid lateral pressure on drills during implant site prepara-tion. Lateral pressure may cause drill fracture.

• Verify the locking of drills in the handpiece before startingany drilling. A loose drill may accidentally harm the patientor members of the surgical team.

• Verify the locking of any interconnecting instruments beforeuse intraorally to prevent accidental swallowing or aspira-tion.

• Always use the drill guard in combination with drills to pre-vent contact between the rotating drill shaft and soft tissue.

Zygoma TiUnite Implant

Position of Zygoma implant

Zygoma Implant (machined)


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Surgery

Standard Le Fort 1 Incision

The reason for using this incision technique is to obtain cover-age of the implant by the periosteum and a wide wound areato minimize the risk of dehiscence during healing. It is recom-mended to make vertical incisions along the infrazygomaticcrest region and to continue the incisions in a downwarddirection, thereby facilitating the exposure of the maxilla andthe zygomatic bone and protecting the parotid gland duct.

Alternative:

Incision can be done on the crest or 10 mm palatally to thecrest to reflect the soft tissue as well as the periosteum up to the level of the zygoma.

The lateral surface of the maxilla is exposed and the infraor-bital foramen identified for the anatomic orientation of thearea prior to installation.

To prevent the involvement of the orbital floor during theimplant installation sequence, extend the exposure in the pos-terior-superior direction to the lateral surface of the zygomaticbone up to the point of the incisura between the zygomaticarch and the lateral and medial surface of the frontal processof the zygomatic bone.

Caution: It is imperative to be aware of neighboring arteries, veinsand nerves in the surgical area. Injures on these anatomical struc-tures might lead to complications such as eye injury, extensivebleeding and nerve related dysfunction.


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Expose the alveolar crest, including the palatal side of the alve-olar crest.

Make a 10 by 5 mm window on the lateral wall of the sinusclose to the infrazygomatic crest.

Ideally, the sinus mucosa should be kept intact during thisprocess. Carefully lift the sinus mucosa away from the areawhere the implant will pass through the sinus, from the floorof the sinus to the roof, trying not to penetrate the mucosa.


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Ideally, plan to place the implant as posteriorly as possible,with the implant head as close to the alveolar crest as possible.Simultaneously, the implant must pass through the sinus closeto the crest of the zygomatic bone and perforate the corticalbone of the zygomatic bone close to the incisura describedpreviously. Adjustment of this ideal placement may be neces-sary due to anatomical variations.

Determine the exact point on the alveolar crest to start thedrilling sequence and the direction of the long axis of theimplant based on the known anatomy of the sinus, the zygo-matic bone and its processes.

Place a retractor at the previously described incisura to facili-tate the correct 3-dimensional orientation of the implant bonesite, with special emphasis on avoiding penetration of theorbital floor.

Due to the length of the drills used for preparing the Zygomaimplant bone site, it is important to protect all the oral soft tis-sues along the drill shaft during drilling. Always use the drillguard to prevent contact between the rotating drill shaft andsoft tissue.


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Operating Instruments

Please refer to the depth measurement system on page 25.

Note! Do not exceed 2.000 rpm when drilling. Sufficient irriga-tion is recommended throughout the drilling sequence.

Make the palatal mark for the implant entrance with theround burr. Penetrate and pass the round burr through tothe sinus while checking the direction of the burr throughthe sinus window. The burr must be directed towards theretractor which was previously placed at the incisura.

Make an entrance mark in the posterior-superior roof of thesinus and then continue with the twist drill, ∅ 2.9 mm whichis available in two lengths, until the drill penetrates the outercortical layer of the zygomatic bone at the incisura.

It it imperative to:

• have full control and to protect the soft tissue at the zygomatic bone penetration site

• have full control of the area where the drill is penetratingthe zygoma and also with a view of the outer cortical layerat the level of the incisura

Now use the straight depth indicator to determine the desiredlength of Zygoma implant to be used.

If the radiographs reveal that the zygomatic bone is thin,make sure the drill is directed towards the lateral surface of theincisura in order to minimize or avoid the medial perforationof the bone with the implant.


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Widen the bone site successively using the following drills:

The pilot drill (diameter) 3.5 mm is available in two lengths. The pilot end is used to find the entrance of the penetration of the sinus roof previously made by the twist drill, ∅ 2.9 mm.2 different lengths of drill guards are available.

The twist drill, ∅ 3.5 mm. which is available in two lengths, isthe last instrument to be used in the drilling sequence.

Verify the depth of the prepared bone site with the angleddepth indicator to ensure that the selected implant length canbe fully seated without apical bone interference.

If the sinus mucosa can not be kept intact, it is essential to pre-vent the mucosa from entering the bone site for the implant. Any mucosal remnants in the bone site may preclude osseointe-gration of the implant.

Take care to ensure the correct angulation and to avoid drillwobble, since this can widen the preparation site.


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Implant installationThere are four special areas of concern when installing theZygoma implant, due to its length and design.

1. Ensure that the implant is guided along the right path ofinsertion through the sinus.

2. If the drilling unit stalls several turns before the final seat-ing position of the implant when the drilling unit is set at45 Ncm , this indicates that the bone site has not beenprepared to its full depth w ith the tw ist drills.

In such an event, back out the implant and prepare the bonesite again to match the chosen implant length. Applyingexcessive torque can distort the implant head or fracture theimplant mount or implant mount screw.

3. Rotate the implant to such a position that the angulatedhexagonal top is directed towards an ideal occlusal plane.This can easily be verified by observing the position of theimplant mount screw which corresponds to the positionof the abutment screw.


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Installation Sequence

Attach the Connection to Handpiece to the handpiece Zygoma.

Please refer to page 23–24 for information about packageopening.

Engage the implant assembly and carry it to the preparedimplant site.

Use slow speed on the drilling unit while engaging the implantapex in the prepared bone site. Confirm the correct insertionangle of the implant while continuing through the sinus untilthe implant apex engages the zygomatic bone.


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Disengage the Connection to Handpiece from the implantmount.

Connect the handle with its adapter end to the implantmount.

Rotate the implant clockwise, using the handle, until thedesired depth and head position is obtained. The implant headcan be positioned accurately by observing the screw whichlocks the implant mount to the implant. The screw positionduplicates the future abutment screw position exactly.

Caution: Do not apply bending forces during this procedure. These forces may distort the implant head or causethe implant mount screw to fracture or loosen. If the hand-wrench has to be used excessively, check the implant mountscrew for loosening and retighten it if necessary.


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When the correct implant head position has been verified,secure the insertion tool with a surgical suture through thehole in the insertion tool.

Use a manual Unigrip Screwdriver or a screwdriver installed onthe contra-angle to remove the insertion tool.

Back out the screw 1 to 2 turns and, if necessary, wiggle theinsertion tool gently from side to side to ensure that it is notbinding on the implant head.

Loosen the screw in the insertion tool completely andremove the screw before removing the insertion tool fromthe implant head.

Caution: The locking screw will always come lose completelywhich will increase the risk for inhalation.

Use a Cover Screwdriver Hexagon Brånemark System to con-nect the cover screw.

Caution: The cover screw must be completely seated to avoid in-growth of bone in the internal threads of the implant head. In-growth of this kind may prevent the complete seating of the per-manent abutment at the time of uncovering if a two-stageprocedure is used.


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SuturingTo m inim ize post-surgical bleeding and to ensure completeclosure of the wound, the follow ing steps should be fol-lowed:

• Start w ith submucosal sutures, using a resorbable suturematerial.

• Use non-resorbable vertical mattress sutures in the submu-cosa and mucosa. This technique m inim izes the risk ofpost-surgical dehiscence formation.

• Place simple sutures between the mattress sutures. Do notsuture them as deeply into the submucosa as the mattresssutures. These sutures assure the liquid tight closure of thewound.

Connection of Healing Abutment Healing Abutments are attached to the implant to allow theformation of a surrounding soft-tissue collar. The abutmentsare available in two lengths. Use the depth gauge for soft tis-sue to measure the amount of tissue through which anopening must be maintained.

1. Open the package containing the abutment.

2. Empty the contents into a sterile bow l.

3. Press the UniGrip Screwdriver into the healing abutmentand carry the assembly to the implant.

4. Screw the abutment into place.

5. Suture the mucosa between the abutments.


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Implant removalThe patient must be informed pre-operatively about the con-sequences of losing a Zygoma implant and the treatment ofsuch a loss.

Failure of a Zygoma implant to osseointegrate or the loss of animplant due to the loss of osseointegration or fracture rendersthe implant useless when it comes to supporting a prostheticrestoration. Such an event may lead to a delay in treatment,additional surgical procedures and/or a change in the treat-ment plan.

To remove the implant, a Zygoma implant mount is securedto the implant with the implant mount screw. The adapterpart of the handle is connected to the implant mount and theimplant is rotated in a counter-clockwise direction until it isfully disengaged from the bone. Any connective tissue in thebone site is carefully removed before a mucoperiosteal flap ispositioned over the entrance and sutured. After a healing peri-od of approximately one year, a new implant can be installed,if so desired.

If a fracture of a Zygoma implant has occurred, the coronalportion of the implant is removed and the apical portion is leftto heal in the bone.


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1. 2.

3. 4.


Packaging - plastic

25

1. 2.

3. 4.

5. 6.

7. 8.


Packaging - glass

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Depth Measurement System

∅ 2.9

∅ 2.9

∅ 2.9

∅ 3.5

∅ 3.5

∅ 3.5

∅ 3.5

5045403530

1.5

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Abutment connection

Uncovering and Abutment Connection

Uncovering of the implant and abutment connection isaccomplished according to standard protocol for BrånemarkSystem® implants when a two-stage procedure is used.

Prosthetic Procedure

Note: Only Brånemark System® Zygoma Abutment Multi-unit (RP)are to be used together with Brånemark System® Zygoma TiUniteimplants. Likewise, only Zygoma abutment Multi-unit (RP) are tobe used together with Zygoma implants.

Clinical procedure

The prosthetic clinical procedure follows the same sequenceas a conventional Brånemark System Regular Platform (RP)case. See Nobel Esthetics Prosthetic Procedure, Multi-unit section.

The prosthetic procedure includes the following steps:

1. Impression

A rigid impression material and impression coping Multi-unit open tray is recommended. An impression of the lowerjaw is also recorded, as well as a preliminary registrationand jaw relation records.

Note: Before taking the impression it is important to verify proper seating of all abutments using intraoral radiographs. Therotational stability of all abutment screws should also be verified.

2. Adjustment and relining of removable prosthesis

It is imperative to carefully adjust the patient’s existing dentureduring the course of the prosthetic treatment. This entails anextensive relief of the palatal base. It is important to ensurethat the healing caps do not interfere with the hard acrylic ofthe denture.


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3. Master cast fabrication

The impression is delivered to the dental laboratory and amaster cast is made. An acrylic record base with a waxocclusal rim is fabricated on this cast.

4. Registration of jaw relations

The record base is attached to the abutments and the occlusalrim is adjusted to the correct vertical height and occlusal planeorientation. Adequate lip support and facial contours are alsoevaluated and appropriate adjustments are made to the occlusalrim. Tooth shape and shade are selected.

5. Tooth set-up in wax

A preliminary tooth set-up is made according to conventionalprosthetic principles.

6. Try-in of preliminary tooth set-up

The wax set-up is tried in the patient. Evaluation of verticaldimension, occlusal relationships, cantilevers, cuspal inclination,tooth shade and shape, hygiene access, lip support, facial con-tours, etc. is made.

7. Framework fabrication

A rigid framework with adequate volume and precision is made.

Cast gold-alloy or precision-milled titanium frameworks (Pro-cera® Implant Bridge) are recommended. A passive fit of theframe-work on the master cast is imperative.

8. Try-in of framework

The passive fit of the framework is verified intra-orally. Use ofmagnification loops facilitates the procedure.


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9. Processing and delivery of final restoration

The passive fit of the final restoration, once fabricated, is veri-fied intra-orally and the retaining prosthetic screws are tight-ened to 15 Ncm. The occlusion is carefully checked and, ifnecessary, adjusted.

Note: Eliminate any primary occlusal contacts on distalcantilevers.

Screw access holes are temporarily sealed and the oral hygieneprocedures are discussed with the patient and necessaryinstructions given. Intra-oral radiographs are recommendedfor verification of component fit and recording of baselinemarginal bone levels.

10. Post-insertion visit

The patient should be seen one to two weeks after delivery fora check-up. The stability of the restoration is checked, and a general evaluation of function, phonetics and estheticsis made. The stability of the bridge retaining gold screws arealso tested and, if necessary, the screws are re-tightened. Thescrew access holes can be permanently sealed. A soft, easilyremoved material is placed over the screw head and a hardfilling material, e.g. composite resin, is placed on top to com-pletely seal the holes.

11. Re-call schedule

A re-call schedule is established based on an individual evalua-tion of each patient’s needs and circumstances. Annual clinicalcheck-ups are recommended, with intra-oral radiographicexaminations after one, three and five years.


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Rigid Bar splintingIn situations when the Zygoma implant has no, or very limited,support by marginal bone, it is recommended to splint theindividual fixtures to each other. This should be done immedi-ately after stage II surgery (abutment connection).

Ideally, an impression is made at the time of stage II surgery.Rubber dam can be used to cover the surgical incisions andsutures. The abutments and impression copings penetrate thedam. A laboratory working cast is poured and gold copingsare attached to the abutment replicas.

A gold bar is then adjusted to fit and is soldered to the goldcopings. The rigid bar is attached to the abutments intra-orallyand secured in place with gold screws.

The patient’s removable prosthesis is carefully adjusted andrelined, using a soft relining material, as previously described.

Cautions:

• The mechanical performance of implants, abutment screws andprosthetic components, as well as longterm osseointegration,may all be adversely effected by lack of passive fit of the restora-tion, inadequate prosthesis design, trauma to the oral regionand various other aspects of biomechanical overload.

• The Zygoma implant can only withstand functional load ifrigidly connected to a minimum of two or more osseointegratedimplants.


31

Brånemark System Zygoma TiUnite™ Implants RP

32245 Implant 30 mm

32246 Implant 35 mm

32247 Implant 40 mm

32248 Implant 42.5 mm

32251 Implant 45 mm


32253 Implant 50 mm


All Brånemark System® Zygoma TiUnite™ Implants are delivered w ith the implantmount pre-mounted. Each package also includes a cover screw.

Note: Brånemark System® Zygoma TiUnite Implants are only to be used together withBrånemark System Zygoma Implant Cover Screws, Brånemark System Zygoma Hea lingAbutments and Brånemark System Zygoma Multi-unit Abutments.

32424 Brånemark System® Zygoma Implant Cover Screw

Brånemark System® Zygoma Healing Abutments32332 ∅ 4 × 3 mm

32333 ∅ 4 × 5 mm

Brånemark System Zygoma Multi-unit Abut-ments RP

32330 Multi-unit 3 mm


Zygoma Implants RP Machined28862 Implant 30 mm

28863 Implant 35 mm

28864 Implant 40 mm


28866 Implant 45 mm


28868 Implant 50 mm


28989 Cover Screw

All Zygoma Implants are delivered w ith the implant mount pre-mounted. Each package also includes a cover screw.

Note: Zygoma Implants are only to be used together with Zygoma Implant Cover Screws and Zygoma Abutments Multi-unit.Use Healing Abutments from standard assortment.

Zygoma Abutments RP




Product Catalog

32

Brånemark System® Zygoma DrillsDIA 578-0 Round Bur

32628 Tw ist Drill ∅ 2.9 mm

32629 Tw ist Drill ∅ 2.9 mm short

32630 Pilot Drill ∅ 3.5 mm

32791 Pilot Drill ∅ 3.5 mm short

32631 Tw ist Drill ∅ 3.5 mm

32632 Tw ist Drill ∅ 3.5 mm short

Zygoma Instruments29162 Zygoma Surgical Kit

Includes: Z handle, Z drill guard, Z drill guard short, Z depth indicator stra ight, Z depth indicator angled.

DIB 097-0 Cover Screw Driver Bmk Syst Hexagon

29152 Screwdriver Machine Unigrip™ 25 mm

(to implant mount screw)29149 Screwdriver Manual Unigrip™ 28 mm

(to implant mount screw)32615 Zygoma Handpiece

(to be used with OsseoSet 100)(semi stra ight ratio 20:1)

29081 Connection to Handpiece Surgical Kit Screwdriver Machine

UniGrip™

Handpiece

Screwdriver ManualUniGrip

Connection toHandpiece


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Achievements

• Inheritors and developers of the work ofProfessor Brånemark – founder of modernimplantology. World leaders in the field

• Providers of the most comprehensive andflexible crown, bridge and implant solutionsin the world

• Creators of unique biocompatible materialTiUnite® for optimal osseointegration,Immediate Function™ and Soft TissueIntegration™

• Creators of CAD/CAM dentistry

• Creators of unique Procera® System –one seam less procedure from 3D planning tofully guided surgery right through to customizedceram ic restoration

• FDA cleared for Immed iate Function™

(except 3.0 and Zygoma)

• FDA cleared for Teeth-In-An-Hour™ in 2004

Quality

• Zero non-conformities in 2004 FDA inspectionof Nobel Biocare production units in Göteborg,Karlskoga and Stockholm

Research

• Formal collaboration w ith over 50 academ icinstitutions and 600 independent scientistsaround the world

• More clinical studies on immediate or earlyloading than all other competitors combined(Medline Feb 2005)

• More prospective clinical studies w ith at least5-year follow-up than all other competitorscombined (Berglund et al 2002)

Support

• 165,000 customers trained by 1,985 dentalprofessionals in 37 countries and in 19 languages,during 2004

• O wn sales organizations w ith local NobelBiocare staff in 29 countries

• Leading business website in 8 languages, withcomplete online service supplying all productsand at least 500 courses available at all times

Nobel Biocare cares about the enviroment and all production units are certified according to the Environmental Management System ISO 14001.

www. nobelb iocare. com

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